CMM-312: Knee Surgery-Arthroscopic and Open Procedures

The policy covers specific arthroscopic and open knee procedures (e.g., diagnostic arthroscopy, debridement/loose body removal, synovectomy, meniscectomy/repair, meniscal allograft, ACL reconstruction and associated ligament procedures) only when procedure‑specific criteria are met, and designates several techniques as experimental/investigational or not covered (e.g., in‑office arthroscopy, ACL repair, hybrid ACI/OATS, subchondroplasty, focal resurfacing implants, and many ACI indications). Coverage requires function‑limiting symptoms with defined physical exam findings, documented failure of provider‑directed non‑surgical management for required durations (typically ≥3 months), and appropriate imaging confirmation with age/BMI and radiographic/lesion‑size limits for cartilage‑restoration and meniscal‑transplant procedures.

"Arthroscopic or open knee surgery for fracture, tumor, infection, or foreign body when surgery is being performed for fracture, tumor, infection, or foreign body that has led to or will likely lead..."